Abdominal Imaging

The multidisciplinary approach in ESC emerged as a result ofefforts to maximize the treatment outcome of this disease.Surgical approach as the only therapeutic option is notalways followed by a good distance survival. A concomitant neoadjuvant radiochemotherapy in ESC may result in afavourable outcome for responding patients, reducing the sizeof the tumor and the degree of lymph node damage increasing resectability and the R0 resection rate, improving prognosis. For non-responding patients or if the disease continues toprogress under RCT therapy, the surgical time is delayed, adverse effects of radiochemotherapy are added and postoperative morbidity and mortality are increased. The imagingmethods for the assessment of response have only limited valueand metabolic response; only FDG-PET manages to comeclose to pathological response. Determining the responsedegree is very important for the establishment of the surgicalconduct: planned or necessity surgery, or non-surgicalpalliative th...

Ovarian teratoma is most frequently found in children and adolescents. It comprises a combination of adult and embryonic tissues from the three germ cell layers: ectoderm, mesoderm, and endoderm. According to the current WHO grading system, the tumor can be divided into mature (benign) and immature (malignant) based on the existence and quantity of the immature component. The microscopic grade of the initial tumor best predicts the chance of extraovarian dissemination, and size and stage have been linked to survival. Immature elements might be present in small foci or large amounts. An incorrect diagnosis of a benign teratoma with inadequate treatment and a poor prognosis can result from insufficient pathological sampling missing the immature tissue. No matter how they present clinically or grossly, all teratomas must be extensively sampled in the pathology lab to look for any potential immature components. A teratoma is challenging for pathologists to diagnose, much like every other gonadal germ cell tumor, and an accurate diagnosis has significant therapeutic and prognostic ramifications. Here, we present the case of a 13-year-old girl with a high-grade metastatic giant 23 cm immature teratoma and review the relevant literature. The patient had several peritoneal implants at the time of surgery, and the tumor had grown to the pelvic wall. Following surgical debulking and chemotherapy, the patient's tumor recurred after two years with liver and lung metastases.

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Purpose Pre-treatment knowledge of the anticipated response of rectal tumors to neoadjuvant chemoradiotherapy (CRT) could help to further optimize the treatment. Van Griethuysen et al. proposed a visual 5-point confidence score to predict the likelihood of response on baseline MRI. Aim was to evaluate this score in a multicenter and multireader study setting and compare it to two simplified (4-point and 2-point) adaptations in terms of diagnostic performance, interobserver agreement (IOA), and reader preference. Methods Twenty-two radiologists from 14 countries (5 MRI-experts,17 general/abdominal radiologists) retrospectively reviewed 90 baseline MRIs to estimate if patients would likely achieve a (near-)complete response (nCR); first using the 5-point score by van Griethuysen (1=highly unlikely to 5=highly likely to achieve nCR), second using a 4-point adaptation (with 1-point each for high-risk T-stage, obvious mesorectal fascia invasion, nodal involvement, and extramural vascular...

Purpose To assess the primary safety and oncological outcome of percutaneous cryoablation in patients with non-visceral metastases of the abdominal cavity after prior surgery. Methods All patients with non-visceral metastases after prior abdominal surgery, treated with percutaneous cryoablation, and at least one year of follow-up were retrospectively identified. Technical success was achieved if the ice-ball had a minimum margin of 10 mm in three dimensions on the per-procedural CT images. Complications were recorded using the Society of Interventional Radiology (SIR) classification system. Time until disease progression was monitored with follow-up CT and/or MRI. Local control was defined as absence of recurrence at the site of ablation. Results Eleven patients underwent cryoablation for 14 non-visceral metastases (mean diameter 20 ± 9 mm). Primary tumor origin was renal cell (n = 4), colorectal (n = 3), granulosa cell (n = 2), endometrium (n = 1) and appendix (n = 1) carcinoma. Tr...

Purpose To analyze how the MRI reporting of rectal cancer has evolved (following guideline updates) in The Netherlands. Methods Retrospective analysis of 712 patients (2011–2018) from 8 teaching hospitals in The Netherlands with available original radiological staging reports that were re-evaluated by a dedicated MR expert using updated guideline criteria. Original reports were classified as “free-text,” “semi-structured,” or “template” and completeness of reporting was documented. Patients were categorized as low versus high risk, first based on the original reports (high risk = cT3-4, cN+, and/or cMRF+) and then based on the expert re-evaluations (high risk = cT3cd-4, cN+, MRF+, and/or EMVI+). Evolutions over time were studied by splitting the inclusion period in 3 equal time periods. Results A significant increase in template reporting was observed (from 1.6 to 17.6–29.6%; p < 0.001), along with a significant increase in the reporting of cT-substage, number of N+ and extrameso...

Purpose: Aim of this study was to evaluate the distribution of persistent mesorectal lymph node metastases on restaging MRI in patients with a good or complete response of their primary tumor (ypT0-2) after CRT for locally advanced rectal cancer. Methods: Two hundred and twenty eight locally advanced rectal cancer patients underwent CRT, which resulted in a good response (downstaging to yT0-2) in 144 patients. Forty-nine patients were excluded (no surgery/insufficient follow-up or lacking lesion-by-lesion histology results). This resulted in a final study group of 95 yT0-2 patients. For the patients with a yN + -status, a detailed lesion-by-lesion comparison between restaging MRI and histology was performed to evaluate the characteristics and distribution of the individual N + -nodes. Results: 7/95 patients (7%) had a yT0-2N + status (11/ 880 (1%) N + nodes): no N + were found below the tumor level, 55% of the N + nodes were located at the level of the tumor, and 45% proximal to the tumor (at a median distance of 1.4 cm above the tumor level). In axial plane, 82% of the nodes were located at the ipsilateral circumference of the tumor, at a median distance of 0.9 cm from the tumor/rectal wall. Conclusions: The incidence of persistent metastatic mesorectal nodes after CRT in patients with a good tumor response after CRT is very low. No N + nodes are found below the tumor level. All N + nodes are located at the level of or proximal to the primary tumor, of which the majority very close to the tumor/lumen.

Aim: The aim of this article was to present a case of epidermoid cyst, which is a rare tumor in this area and has some specific imaging features. To our knowledge, intracranial epidermoid cysts and its imaging features were often described, but only a few cases have been previously reported with imaging fetaures of presacral epidemoid cysts. Case report: A 32-year-old woman presented with symptoms of difficult labor, and during the childbirth, a large tumor pressing from behind in to the birth canal was noticed. After recovery, multislice computerized tomography (MSCT) with intravenous contrast administration was performed. A cystic lesion in the presacral space on the left side with thin ring enhancement and no internal enhancement was demonstrated. Further magnetic resonance imaging (MRI) showed morphologic features of epidermoid cyst with high protein content (heterogenous signal on T1W and T2W). Surgery was performed and pathohistological analysis confirmed the diagnosis of epid...

Background: Placenta accreta spectrum (PAS) disorders encompass a heterogeneous group of anomalies characterized by abnormal adhesion or invasion of the trophoblastic tissue into the myometrium. Advances in prenatal imaging techniques and improved knowledge of the natural history of these anomalies have led to an increase in the prenatal detection rate of PAS disorders. Prenatal diagnosis of a PAS disorder is fundamental as it has been shown to reduce the burden of maternal morbidity by allowing preplanned treatment in centers with high expertise in surgical management of this condition. TVS is often recommended to identify the cervical canal, internal os, and the relationship between the leading placental edge and the internal os; it can also be used for a focused evaluation of the lower uterine wall and the bladder interface Histopathology is now widely considered as the gold standard modality recommended to confirm clinical diagnosis of PAS. The aim of our study was to compare be...

We report a case of delayed biliary leak following left hepatectomy with bile duct excision causing repeated infection. The focal dilatation of bile duct system responsible for biliary leak through the liver surface from residual segment 4 was targeted selectively by CT guidance and ablated with alcohol causing complete resolution of the bile leak and the subsequent infection. Ravindra Kamble1*, Vikram Belliappa2, Sanjeev Mudakavi1, Megha Jayaram1, Prakash P1, Raghavendra B Kudasomannavar2 and Sunil Kumar CS2 1Department of Radiology, Vikram Hospital, India 2Department of Hepatobiliary Surgery, Vikram Hospital, India Annals of Clinical Case Reports Radiology Remedy Publications LLC., | http://anncaserep.com/ 2020 | Volume 5 | Article 1835 2 Ravindra Kamble, et al., carefully monitored for any adverse effects. Since the patient did not report any discomfort, he was then discharged and asked to report for follow-up. Repeat CT scan done after 1 month showed minimal residual collection ...

The development of gastric carcinoma in a patient with gastric lymphoma is rare. Helicobacter pylori is a common etiologic agent for both these conditions. We report a 38-year-old lady who was initially diagnosed to have gastric lymphoma and developed early gastric carcinoma on follow up. She was operated on for the carcinoma and is in complete remission since.

Relaparotomy may be beneficial in patients developing intraperitoneal sepsis after abdominal procedures. We determined whether joint clinical assessment by intensivist and surgeon (clinician assessment) identified patients with surgically correctable intraperitoneal sepsis. We also assessed the effect of patient age and sex, disease presentation and severity, interval to relaparotomy, and the number of relaparotomies on survival after relaparotomy. Data on clinical, laboratory, and radiologic abnormalities prior to relaparotomy, relaparotomy findings, and in-hospital survival were prospectively collected on a general hospital intensive care unit (ICU) database between January 1997 and January 2002. Altogether, 65 of 1482 (4.4%) patients admitted to the ICU after abdominal surgery underwent relaparotomy at a median of 5 days after the initial procedure. There was an 83% probability of identifying surgically treatable sepsis and 43% inhospital mortality. Abdominal imaging contributed accurate information in 50% of cases where clinician assessment was uncertain. Patient age and multiorgan failure prior to relaparotomy-but not urgency of initial laparotomy or the acute physiology and chronic health evaluation (APACHE II) score prior to relaparotomy, interval to relaparotomy, or number of relaparotomies-affected the outcome. Clinician assessment after abdominal surgery had a high probability of predicting intraperitoneal sepsis at relaparotomy. The 43% mortality after relaparotomy was unlikely to be greater than with nonoperative treatment of intraabdominal sepsis, but the 78% mortality after relaparotomy in patients older than 75 years of age raised doubts about this approach in the elderly. The identification of intraperitoneal sepsis and performance of relaparotomy earlier after the initial abdominal surgery might reduce the high rate (60%) of multiorgan failure prior to relaparotomy and improve survival after it.

Objective-To determine if tumor cell density and percentage of Gleason pattern within an outlined volumetric tumor region of interest (TROI) on whole-mount pathology (WMP) correlate with ADC values on corresponding TROIs outlined on pre-operative MRI. Methods-Men with biopsy-proven prostate adenocarcinoma undergoing multiparametric MRI (mpMRI) prior to prostatectomy were consented to this prospective study. WMP and mpMRI images were viewed using 3D Slicer and each TROI from WMP was contoured on the high bvalue ADC maps (b0, 1400). For each TROI outlined on WMP, TCD (tumor cell density) and the percentage of Gleason pattern 3, 4, and 5 were recorded. The ADC mean , ADC 10th percentile , ADC 90th percentile , and ADC ratio were also calculated in each case from the ADC maps using 3D Slicer.

Purpose-To determine the accuracy of in-bore transperineal 3-Tesla (T) magnetic resonance (MR) imaging-guided prostate biopsies for predicting final Gleason grades in patients who subsequently underwent radical prostatectomy (RP). Methods-A retrospective review of men who underwent transperineal MR imaging-guided prostate biopsy (tpMRGB) with subsequent radical prostatectomy within 1 year was conducted from 2010-2015. All patients underwent a baseline 3-T multiparametric MRI (mpMRI) with endorectal coil and were selected for biopsy based on MR findings of a suspicious prostate lesion and high degree of clinical suspicion for cancer. Spearman correlation was performed to assess concordance between tpMRGB and final RP pathology among patients with and without previous transrectal ultrasound (TRUS)-guided biopsies. Results-A total of 24 men met all eligibility requirements, with a median age of 65 years (interquartile range [IQR] 11.7). The median time from biopsy to RP was 85 days (IQR 50.5). Final pathology revealed Gleason 3+4=7 in 12 patients, 4+3=7 in 10 patients, and 4+4=8 in 2 patients. A strong correlation (ρ: +0.75, p<0.001) between tpMRGB and RP results was observed, with Gleason scores concordant in 17 cases (71%). 16 of the 24 patients underwent prior TRUS biopsies. Subsequent tpMRGB revealed Gleason upgrading in 88% of cases, which was concordant with RP Gleason scores in 69% of cases (ρ: +0.75, p<0.001).

Purpose-To compare diagnostic performance of PI-RADSv2 with ADC parameters to identify clinically significant prostate cancer (csPC) and to determine the impact of csPC definitions on diagnostic performance of ADC and PI-RADSv2. Methods-We retrospectively identified treatment-naïve pathology-proven peripheral zone PC patients who underwent 3T prostate MRI, using high b-value diffusion-weighted imaging from 2011-2015. Using 3D slicer, areas of suspected tumor (T) and normal tissue (N) on ADC (b=0,1400) were outlined volumetrically. Mean ADC T , mean ADC N , ADC ratio (ADC T /ADC N ) were calculated. PI-RADSv2 was assigned. Three csPC definitions were used: (A) Gleason score (GS)≥4+3; (B) GS≥3+4; (C) MRI-based tumor volume>0.5cc. Performances of ADC parameters and PI-RADSv2 in identifying csPC were measured using nonparametric comparison of receiver operating characteristic curves using the area under the curve (AUC). Results-85 cases met eligibility requirements. Diagnostic performances (AUC) in identifying csPC using 3 definitions were: (A) ADC T (0.83) was higher than PI-RADSv2 (0.65, p=0.006); (B) ADC T (0.86) was higher than ADC ratio (0.68, p<0.001), and PI-RADSv2 (0.70, p=0.04); (C) PI-RADSv2 (0.73) performed better than ADC ratio (0.56, p=0.02). ADC T performance was higher when csPC was defined by A or B versus C (p=0.038 and p=0.01, respectively). ADC ratio

This study, which was based on a large series of consecutive patients imaged by 111 In-pentetreotide SPECT for a neuroendocrine tumor, evaluated variability in reconstruction parameters in relation to patient body weight and the body region imaged, looking for the possibility of standardizing such parameters. Methods: One hundred twenty-four patients underwent 111 Inpentetreotide scintigraphy: 4-and 24-h whole-body and planar scans and a 24-h SPECT examination. All patients were injected with 140-150 MBq of 111 In-pentetreotide at least 1 wk after somatostatin analogs had been discontinued. SPECT images were systematically acquired at the levels of the head, chest, and abdomen. SPECT was performed using a dual-head g-camera with medium-energy collimators, step-and-shoot method, no circular orbit, a 64 • 64 matrix, and 30 s per view for a total of 64 views. Two reconstruction procedures were compared: the iterative method using 10 iterations and the filtered backprojection method using a Butterworth filter with different cutoffs and orders. Results: Optimal SPECT images were obtained by applying the Butterworth filter. The reconstruction parameters could be standardized for the head and chest but were more variable for the abdomen, mainly because 111 In-pentetreotide is physiologically trapped in different intestinal areas and varies over time, especially in the liver, spleen, bowel, and urinary tract. Conclusion: Filtered backprojection using a Butterworth filter appears adequate for standardizing the reconstruction parameters for 111 In-pentetreotide SPECT of the head and chest. Processing of abdominal images is more operator-dependent. A 150-MBq dose of 111 In-pentetreotide is recommended when planning multiple SPECT acquisitions in the same patient.

Intrauterine devices (IUDs) are commonly used as a contraceptive method. However, they may cause rare but potentially serious complications such as migration through the uterine wall and gastrointestinal perforation. We report a case of a 26-year woman, carrying an IUD for 2 years, who presented to the emergency with pelvic pain with breakthrough bleeding. Abdominal imaging revealed the presence of two devices the first of which was located in the uterine cavity and the other in the wall of the sigmoid colon associated with a 5-centimeter pelvic collection. Intraoperatively, the IUD was found to be embedded in the wall of the sigmoid colon which was removed by wedge resection of the involved segment followed by a closure of the puncture with drainage. The Intrauterine Device (IUD) is an effective method of contraception, relatively well tolerated, reversible, inexpensive and widely used. However, it is not without risk. Indeed, serious complications can occur such as uterine perfora...

Irreversible electroporation (IRE) is an innovative local-regional therapy that involves delivery of intense electrical pulses to tissue to induce nanoscale cell membrane defects for tissue ablation. The purpose of this study was to investigate the feasibility of using IRE as a liver-directed ablation technique for the treatment of hepatocellular carcinoma (HCC). In the N1-S1 rodent model, hepatomas were grown in 30 Sprague-Dawley rats that were divided into treatment and control groups. For treatment groups, IRE electrodes were inserted and eight 100-μs 2,500-V pulses were applied to ablate the targeted tumor tissues. For both groups, magnetic resonance imaging scans were performed at baseline and 15-day follow-up intervals to determine tumor sizes (one-dimensional maximum diameter, Dmax; estimated two-dimensional cross-sectional area, Cmax) as a tactic to assess longitudinal outcomes. Additional groups of treated animals were sacrificed at 1-, 3-, and 7-day intervals posttherapy f...

Anisakiasis, a zoonotic disease that can lead to small intestine obstruction, has seen a significant rise in Spain. The country has become the first in Europe with an annual incidence of 8000 cases, primarily due to the popularity of consuming exotic dishes of undercooked or raw fish and the impact of climate change. The clinical presentation of anisakiasis can mimic symptoms of acute appendicitis or intestinal obstruction, leading to potential misdiagnosis. This case report describes a 37-year-old patient with no significant medical history who presented abdominal distension and intense pain in the right lower quadrant. The patient underwent surgery and received physiotherapy treatment, including therapeutic exercises and pulsed-pressure myofascial vacuum therapy, to facilitate functional recovery. The increasing incidence of anisakiasis in Spain underscores the need to consider it in the differential diagnosis of digestive diseases, given the high consumption of poorly prepared or...

Angiogenesis is a complex event mediated by angiogenic factors released from cancer cells and immune cells. It has been reported to be associated with progression, aggressiveness and metastases of various malignant tumors including oral squamous cell carcinoma (OSCC). Similarly, mast cells have also been reported to play a role in tumor progression and metastases by promoting angiogenesis. Objectives: The present study was conducted to compare microvessel density (MVD) and mast cell density (MCD) in different histological grades of OSCC in comparison with normal oral mucosa (NM). Materials and Methods: Comparison of MVD by CD34 and MCD by toluidine blue among different histological grades of OSCC and in NM as controls. Statistical Analysis: The results were analysed using 't" test, ANOVA and Pearson's correlation co-efficient. Results: The mean MVD was higher in different grades as compared to normal mucosa. Intergroup comparison of increase in MVD between different grades of OSCC was not found to be highly statistically significant. Pearson's correlation between MVD and MCD revealed a linear increase in MVD as the MCD increased, suggestive of a positive correlation. There was significant correlation found between MVD and MCD which was in agreement that mast cells promote tumor progression through upregulation of angiogenesis.

Wireless capsule endoscopy is currently considered the gold standard in the investigation of the small bowel. It is both practical for physicians and easily accepted by patients. Prior to its development, two types of imaging investigations of the small bowel were available: radiologic and endoscopic. The first category is less invasive and comfortable for patients; it presents the ensemble of the small bowel, but it may imply radiation exposure. Images are constructed based on signals emitted by various equipment and require special interpretation. Endoscopic techniques provide real-time colored images acquired by miniature cameras from inside the small bowel, require interpretation only from a medical point of view, may allow the possibility to perform biopsies, but the investigation only covers a part of the small bowel and are more difficult to accept by patients. Wireless capsule endoscopy is the current solution that overcomes a part of the previous drawbacks: it covers the entire small bowel, it provides real-time images acquired by cameras, it is painless for patients, and it represents an abundant source of information for physicians. Yet, it lacks motion control and the possibility to perform biopsies or administer drugs. However, significant effort has been oriented in these directions by technical and medical teams, and more advanced capsules will surely be available in the following years. Contents 1. Introduction 2. Brief history of small bowel investigation 3. A brilliant idea 4. Wireless capsule endoscopy (WCE) 5. WCE systems 6. Uses for WCE 7. The future of WCE

Summary In this study 50 patients (36 male, 14 female) with oesophageal carcinoma have been examined preoperatively by computed tomography. Three parameters were assessed, nodal involvement, invasion of adjacent organs, and metastatic disease. For all patients the computed tomography findings were correlated with the subsequent surgical and pathological findings. Sensitivity for both invasion and node involvement is low (36% to 67%). Specificity however, is high (85% to 95%). Computed tomography is therefore relatively reliable when it predicts a ‘negative result’ for either invasion or node involvement. However, its predictive value for a positive result is not as reliable.

Choledochal cysts are rare congenital cystic dilatations of the biliary tree. They are most commonly present in female infants and young children, and their pathology remains unclear. The triad of intermittent jaundice, abdominal mass, and pain is found only in a minority of patients. Diagnosis and delineation of accurate biliary anatomy are crucial for surgical planning. This is most often successfully achieved with ultrasound and magnetic resonance cholangiopancreatography. The definitive treatment is cyst excision which decreases the risk of biliary carcinoma. We present an unusual case of a choledochal cyst in an adolescent boy with a review of the literature and emphasis on multi-imaging modalities, including the role of liver-specific gadolinium contrast agents in challenging cases to confirm the diagnosis.

Purpose: Aim of this study was to evaluate the distribution of persistent mesorectal lymph node metastases on restaging MRI in patients with a good or complete response of their primary tumor (ypT0-2) after CRT for locally advanced rectal cancer. Methods: Two hundred and twenty eight locally advanced rectal cancer patients underwent CRT, which resulted in a good response (downstaging to yT0-2) in 144 patients. Forty-nine patients were excluded (no surgery/insufficient follow-up or lacking lesion-by-lesion histology results). This resulted in a final study group of 95 yT0-2 patients. For the patients with a yN + -status, a detailed lesion-by-lesion comparison between restaging MRI and histology was performed to evaluate the characteristics and distribution of the individual N + -nodes. Results: 7/95 patients (7%) had a yT0-2N + status (11/ 880 (1%) N + nodes): no N + were found below the tumor level, 55% of the N + nodes were located at the level of the tumor, and 45% proximal to the tumor (at a median distance of 1.4 cm above the tumor level). In axial plane, 82% of the nodes were located at the ipsilateral circumference of the tumor, at a median distance of 0.9 cm from the tumor/rectal wall. Conclusions: The incidence of persistent metastatic mesorectal nodes after CRT in patients with a good tumor response after CRT is very low. No N + nodes are found below the tumor level. All N + nodes are located at the level of or proximal to the primary tumor, of which the majority very close to the tumor/lumen.

The aim of this study was to assess correlation between quantitative and semiquantitative parameters in dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) in rectal cancer patients, both in a primary staging and restaging setting. Nineteen patients were included with DCE-MRI before and/or after neoadjuvant therapy. DCE-MRI was performed with gadofosveset trisodium (Ablavar(®), Lantheus Medical Imaging, North Billerica, Massachusetts, USA). Regions of interest were placed in the tumor and quantitative parameters were extracted with Olea Sphere 2.2 software permeability module using the extended Tofts model. Semiquantitative parameters were calculated on a pixel-by-pixel basis. Spearman rank correlation tests were used for assessment of correlation between parameters. A p value ≤0.05 was considered statistically significant. Strong positive correlations were found between mean peak enhancement and mean K trans: 0.79 (all patients, p&lt;0.0001), 0.83 (primary staging, p = 0...

Purpose: Aim of this study was to evaluate the distribution of persistent mesorectal lymph node metastases on restaging MRI in patients with a good or complete response of their primary tumor (ypT0-2) after CRT for locally advanced rectal cancer. Methods: Two hundred and twenty eight locally advanced rectal cancer patients underwent CRT, which resulted in a good response (downstaging to yT0-2) in 144 patients. Forty-nine patients were excluded (no surgery/insufficient follow-up or lacking lesion-by-lesion histology results). This resulted in a final study group of 95 yT0-2 patients. For the patients with a yN + -status, a detailed lesion-by-lesion comparison between restaging MRI and histology was performed to evaluate the characteristics and distribution of the individual N + -nodes. Results: 7/95 patients (7%) had a yT0-2N + status (11/ 880 (1%) N + nodes): no N + were found below the tumor level, 55% of the N + nodes were located at the level of the tumor, and 45% proximal to the tumor (at a median distance of 1.4 cm above the tumor level). In axial plane, 82% of the nodes were located at the ipsilateral circumference of the tumor, at a median distance of 0.9 cm from the tumor/rectal wall. Conclusions: The incidence of persistent metastatic mesorectal nodes after CRT in patients with a good tumor response after CRT is very low. No N + nodes are found below the tumor level. All N + nodes are located at the level of or proximal to the primary tumor, of which the majority very close to the tumor/lumen.

Purpose With the spread of transjugular intrahepatic portosystemic shunts (TIPS), portosystemic shunt surgery (PSSS) has decreased and leaves more complex patients with great demands for accurate preoperative planning. The aim was to evaluate the role of imaging for predicting the most suitable PSSS approach. Material and methods Forty-four patients who underwent PSSS (2002 to 2013) were examined by contrast-enhanced CT (n = 33) and/or MRI (n = 15) prior to surgery. Imaging was analyzed independently by two observers (O1 and O2) with different levels of experience (O1 &gt; O2). They recommended two shunting techniques (vessels and anastomotic variant) for each patient and ranked them according to their appropriateness and complexity. Findings were compared with the actually performed shunt procedure and its outcome. Results The first two choices taken together covered the performed PSSS regarding vessels in 88%/100% (CT/MRI, O1) and 76%/73% (O2); and vessels + anastomosis in 79%/73%...

Barium studies of the upper gastrointestinal tract and small bowel were performed in 16 adult patients with biopsy-proven nontropical sprue. Commercially available contrast media containing micropulverized barium sulfate, suspending agents, and various other additives were used. Radiographs were analyzed for the incidence and pattern of duodenal vs. small-bowel changes associated with celiac disease. Thirteen of 16 patients (81%) demonstrated abnormalities of the duodenum which ranged from focal erosions to diffusely thickened and nodular folds. A nonspecific, mild dilatation pattern was present on the small-bowel series of 11 patients (69%). The classic radiographic signs of malabsorption, such as flocculation and segmentation, however, occurred in less than 20% of cases, apparently because of the stability of new barium suspensions. The pathogenesis of duodenal changes in sprue and its diagnostic implications are emphasized.

Sickle cell disease (SCD) is the most prevalent hemoglobinopathy. Survival in patients with SCD has improved over the past few decades. These patients experience a lifetime of repeated acute pain crises, which are thought to result from sickling and microvascular occlusions; acute abdominal pain is common. Moreover, repeated crises often lead to organ dysfunction, such as asplenia, hepatic failure, and renal failure. The spleen, liver, biliary system, kidneys, and gastrointestinal tract can all be affected. Patients may undergo CT to further direct clinical management. We review the spectrum of CT imaging findings of abdominal manifestations in patients with SCD, from the acute microvascular occlusive pain crisis to the potential complications and chronic sequelae.

Insulinomas are rare neuroendocrine tumors which occur predominantly in the pancreas. Although majority of the insulinomas are benign, over-secretion of insulin by the tumor leads to debilitating hypoglycemic symptoms. The diagnosis is based on clinical and biochemical findings. After the diagnosis is made, the principal challenge lies in locating the tumor because most tumors are solitary and small in size. Locating the tumor is of paramount importance as complete surgical excision is the only curative treatment, and incomplete resection leads to persistence of symptoms. Different preoperative and intraoperative imaging techniques have been used with varying success rates for the insulinoma imaging. Besides localizing the tumor, imaging also helps to guide biopsy, detect metastatic lesions, and perform image-guided therapeutic procedures. This review will discuss the role of different Cross sectional and nuclear medicine imaging modalities in insulinomas.

Peritoneal disease can be caused by a wide spectrum of pathologies. While peritoneal disease is usually caused by primary or secondary malignancies, benign diseases can occur and mimic malignancies. This article begins with an overview of peritoneal embryology and anatomy followed by a detailed description of the multimodality imaging appearance of peritoneal diseases. Common diseases include peritoneal carcinomatosis, pseudomyxoma peritonei, lymphomatosis, sarcomatosis, and tuberculous peritonitis. The uncommon diseases which cause peritoneal disease include desmoid fibromatosis, desmoplastic small round cell tumor, malignant mesothelioma, well-differentiated mesothelioma, multicystic mesothelioma, papillary serous carcinoma, leiomyomatosis, extramedullary hematopoiesis, inflammatory pseudotumor and amyloidosis. This manuscript will help the radiologist become familiar with the different peritoneal spaces, pathways of spread, multimodality imaging appearance and differential diagnoses of peritoneal diseases in order to report the essential information for surgeons and oncologists to plan treatment.

Various hematopoietic neoplasms can involve the female genital system. The most common hematological malignancy that involves the female genital system is lymphoma and secondary involvement is more common than primary genital lymphoma. Rarely, leukemic infiltration and extramedullary plasmacytomas of the female genital tract may also occur. Being infrequent, these lesions are commonly misdiagnosed radiologically. Therefore, understanding these malignancies of the female genital system and recognizing their imaging features are of utmost clinical importance. Although definitive diagnosis can be made only by histological analysis, imaging of these tumors plays an important role in detecting lesion extensions, guiding biopsies, staging disease, planning therapy, and detecting recurrence.

Objective: Establish the efficiency of 6-and 12-punctures transrectal ultrasound-guided needle biopsies in low risk patients for prostate cancer. Six-punctures (sextant) biopsies were compared to 12-punctures biopsies, assessing which is the best strategy to detect this neoplasm. Materials and Methods: Among 240 patients submitted to prostate biopsy, 54 with suspected small and organ-localized tumors (prostatic specific antigen ≤ 10 ng/mL and digital exam of the prostate not suggesting cancer) in glands < 50 cm 3 were selected, constituting a homogenous sample. These patients were submitted to standard 3-punctures (basal, mid, and apical) sextant biopsy in parasagittal midline of each prostatic lobe, with 3 additional lateral punctures, bilaterally. Each specimen was separately submitted to histological study. Results: Twenty-two (40.7%) patients had prostatic cancer, and 28 presented prostatic hyperplasia, associated or not to inflammatory conditions. High-grade prostatic intraepithelial neoplasia (PIN) was detected in 4 patients. From 22 tumors detected by 12-punctures biopsies, 6-punctures biopsies in the parasagittal midline (sextant) diagnosed 50% of the cases, while isolated lateral punctures diagnosed 90.9% of the malignant neoplasms. Basal lateral punctures responded for 72.7% of the cancer diagnosis, while basal sextant punctures responded only for 9.1% of the cases. Conclusion: For low risk prostate cancer, patients' 12-punctures biopsy was more effective, for sextant biopsy failed to diagnose half of the cases of neoplasm. Three lateral punctures (basal, mid, and apical), with 2 additional punctures in the parasagittal midline (mid and apical) bilaterally are suggested as the best biopsy strategy.

Background: The most frequent complication of liver hydatid cyst is intrabiliary rupture (LHCIBR). This study aimed to investigate preoperative predictive factors of occult and frank LHCIBR. Methods: We conducted a retrospective study concerning patients operated on consecutively for liver hydatidosis for 2 years. Patients were divided into three groups: who had no intrabiliary rupture, patients who had an occult rupture and patients who had a frank rupture. Results: We recorded 56 patients with 82 liver hydatid cysts. LHCIBR was occult in 16 cysts and frank in four cysts. Bivariate analysis identified jaundice and cyst size as associated with frank LHCIBR and US cyst type II or III, recurrent cyst, and size of the hydatid cyst as associated with occult LHCIBR. In the multivariate analysis, we retained jaundice, cyst size > 6.5 cm and duration of symptoms > 45 days as significant predictive factors of frank rupture and cyst size > 6.5 cm, number of recurrences ≥ 3, cyst type II or III, leukocytosis > 9.000/mm 3 and eosinophilia > 5.5% as significant of occult rupture. Conclusion: Misdiagnosis LHCIBR can lead to increased morbidity and mortality. They were avoided by predicting cyst rupture, correct timing and type surgery, proper drainage and preoperative intensive care of patients.

Purpose: To compare two different imaging modalities, magnetic resonance (MR), and three-dimensional sonography (3DUS), in order to evaluate the specific role in preoperative work-up of deep infiltrating endometriosis. Materials and methods: 33 women with endometriosis underwent 3DUS and MR followed by surgical and histopathological investigations. Investigators described the disease extension in the following sites: torus uterinus and uterosacral ligaments (USL), vagina, rectovaginalseptum, rectosigmoid, bladder, ovaries. Results were compared with surgical and histopathological findings. Results: Ovarian and deep pelvic endometriosis were found by surgery and histology in, respectively, 24 (72.7%) and 22 (66.6%) of the 33 patients. Sensitivity and specificity values of 3DUS for the diagnosis of endometrial cysts were 87.5% and 100%, respectively; those of MRI were 96.8% and 91.1%, respectively. Sensitivity and specificity of 3DUS for the diagnosis of deep infiltrating endometriosis in specific sites were: USL 50% and 94.7%; vagina 84% and 80%; rectovaginalseptum 76.9% and 100%; rectosigmoid 33.3% and 100%; bladder 25% and 100%. Those of MR were: USL 69.2% and 94.3%; vagina 83.3% and 88.8%; rectovaginalseptum 76.4% and 100%; restosigmoid 75% and 100%; bladder 83.3% and 100%. Conclusions: MR accurately diagnoses deep infiltrating endometriosis; 3DUS accurately diagnoses deep infiltrating endometriosis in specific locations.

A total of 132 patients who had dynamic magnetic resonance imaging (MRI)/computed tomography (CT) images in the Picture Archiving and Communication Systems (PACS) with liver nodule were included in the study, 37 of whom had histopathology results. Five radiologists who participated in the study, interpreted liver nodules independently on different PACS stations according to the LIRADS reporting system and its main parameters. We determined that level of inter-observer agreement in the LR-1, LR-5, and LR-5V categories was higher than in the LR-2, LR-3, and LR-4 categories (κ = 0.522, 0.442, and 0.600 in the LR-1, LR-5, and LR-5V categories, respectively; κ = 0.082, 0.298, and 0.143 in the LR-2, LR-3, and LR-4 categories, respectively). The parameter that we observed to have the highest level of inter-observer agreement was venous thrombus (κ = 0.600). Our study showed that LIRADS achieves an acceptable inter-observer reproducibility in terms of clinical practice although it is insufficient at intermediate risk levels. We think that the prevalence of its use will be further increased with training related to the subject and the assignment of numerical values that express the probability of malignancy for each category and including the ancillary features in the algorithm according to clearer rules.

Renal angiomyolipomas (AMLs) are the most common benign tumours of the kidney that occur sporadically in 80% of the patients and are seen associated with genetic conditions such as tuberous sclerosis in rest of the patients. The diagnosis of renal AML pre-operatively have been made easier with the advent of good imaging modalities. The management of these tumours depends on factors such as size, clinical presentation, extent of parenchymal involvement and ranges from a wait and watch strategy to a radical nephrectomy. Herewith, we reported of a giant renal AML who presented with complaints of lump in abdomen with headache and palpitations. She was diagnosed to have a giant renal AML on imaging. The patient was managed with radical nephrectomy after renal AML. A brief case report with review literature was presented here.

We present a case of primary esophageal tuberculosis presenting as solitary submucosal mass in cervical esophagus with clinical features of dysphagia, thus mimicking a submucosal leiomyoma on imaging in a 39 year old lady. Excision of this mass revealed features suggestive of tuberculosis on histopathology.

Background/aims: This study was undertaken to evaluate the effectiveness of combination therapy with transcatheter arterial chemoembolization followed by percutaneous ethanol injection in patients with unresectable large hepatocellular carcinoma by comparing the use of this combined regimen with transcatheter arterial chemoembolization alone. Methodology: Six hundred and thirty-one consecutive patients with hepatocellular carcinoma lesions observed from Jan 1989 to Dec 1999 (11 years) at the Internal Medicine Department, Saga Prefectural Hospital Koseikan were retrospectively enrolled in the study. The series included 120 patients with large unresectable hepatocellular carcinoma lesions, the largest of which were greater than 3 cm in largest dimension. Fifty-two patients underwent a single transcatheter arterial chemoembolization followed by percutaneous ethanol injection, which were compared with 68 patients treated by transcatheter arterial chemoembolization alone. Both groups of patients with hepatocellular carcinoma did not differ regarding the base-line characteristics. The overall survival rates and recurrence ratio of initially treated lesions were compared in both groups. Results: On overall survival rates by the Kaplan-Meier method, three- and five-year survival in the transcatheter arterial chemoembolization and percutaneous ethanol injection group (59.0%, 32.1%) proved to be significantly longer than those in the transcatheter arterial chemoembolization group (27.1%, 17.0%). In addition, during the follow-up local recurrence in the combination group (23.1%) was significantly lower than that in the transcatheter arterial chemoembolization group (50.0%). Conclusions: The combined treatment with transcatheter arterial chemoembolization and percutaneous ethanol injection proved to be more effective and safer. Furthermore, a lower incidence of local recurrence was observed than transcatheter arterial chemoembolization alone which resulted in an increased survival of the patients associated with unresectable large hepatocellular carcinoma lesions.

The apparent diffusion coefficient (ADC) is a potential prognostic imaging marker in rectal cancer. Typically, mean ADC values are used, derived from precise manual whole-volume tumor delineations by experts. The aim was first to explore whether non-precise circular delineation combined with histogram analysis can be a less cumbersome alternative to acquire similar ADC measurements and second to explore whether histogram analyses provide additional prognostic information. Thirty-seven patients who underwent a primary staging MRI including diffusion-weighted imaging (DWI; b0, 25, 50, 100, 500, 1000; 1.5 T) were included. Volumes-of-interest (VOIs) were drawn on b1000-DWI: (a) precise delineation, manually tracing tumor boundaries (2 expert readers), and (b) non-precise delineation, drawing circular VOIs with a wide margin around the tumor (2 non-experts). Mean ADC and histogram metrics (mean, min, max, median, SD, skewness, kurtosis, 5th-95th percentiles) were derived from the VOIs a...

Objectives: Magnetic resonance imaging (MRI) is not accurate in discriminating T1-2 from borderline T3 rectal tumors. Higher resolution on 3 Tesla-(3T)-MRI could improve diagnostic performance for T-staging. The aim of this study was to determine whether 3T-MRI compared with 1.5 Tesla-(1.5T)-MRI improves the accuracy for the discrimination between T1-2 and borderline T3 rectal tumors and to evaluate reproducibility. Methods: 13 patients with non-locally advanced rectal cancer underwent imaging with both 1.5T and 3T-MRI. Three readers with different expertise evaluated the images and predicted T-stage with a confidence level score. Receiver operator characteristics curves with areas under the curve (AUC) and diagnostic parameters were calculated. Inter-and intra-observer agreements were calculated with quadratic kappa-weighting. Histology was the reference standard. Results: Seven patients had pT1-2 tumors and six had pT3 tumors. AUCs ranged from 0.66 to 0.87 at 1.5T vs. 0.52-0.82 at 3T. Mean overstaging rate was 43% at 1.5T and 57% at 3T (P = 0.23). Inter-observer agreement was j 0.50-0.71 at 1.5T vs. 0.15-0.68 at 3T. Intra-observer agreement was j 0.71 at 1.5T and 0.76 at 3T. Conclusions: This is the first study to compare 3T with 1.5T MRI for T-staging of rectal cancer within the same patients. Our results showed no difference between 3T and 1.5T-MRI for the distinction between T1-2 and borderline T3 tumors, regardless of expertise. The higher resolution at 3T-MRI did not aid in the distinction between desmoplasia in T1-2-tumors and tumor stranding in T3-tumors. Larger studies are needed to acknowledge these findings.